Fire crews confront the opioid epidemic daily in the most personal of ways.

They tend to the users who can't stay awake. They administer naloxone, the reversal drug that brings addicts back from a life-threatening overdose. And they answer the call when an unresponsive person is found in a parked car, a gas station bathroom or a neighborhood — impoverished or affluent.

They see the scourge. Many are frustrated with their reactive role of merely responding and treating. They want to be more involved in helping people find a solution.

But despite running on 5,458 reported overdose calls last year — up 21 percent since 2013 and an average of 15 each day — firefighters on the front lines of the opioid epidemic in Phoenix don't know where they factor into broader substance-abuse solutions.

Or if they can feasibly factor in at all.

PART 1: Phoenix firefighters deal with opioids every day. But do they fit into a solution?

Despite the surge in opioid-involved emergency calls, fire departments are barely mentioned in Arizona's 106-page "opioid action plan." The words "fire department" are referenced one time in that report, discussing the merits of so-called Safe Station facilities pioneered on the East Coast and deemed worthy of consideration by public healthofficials.

Even though that document was used as a framework to inform a series of overdose-related measures last month, it's unclear exactly how, or even if, such a program will come to the Valley. It is not something the state health department is actively pursuing.

State officials acknowledge the slow-to-change nature work of reactive first responders, yet they're adamant community-based changes are on the horizon in Arizona.

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Still, many wonder how foot soldiers for the opioid epidemic can move from being "reactive" in the realm of emergency response to "proactive" in pursuit of a solution, said Capt. Rob McDade, a paramedic who has been with the Phoenix Fire Department for 17 years.

"As far as first responders, EMS and fire, we’re having a hard time finding that place," he said. "It’s very frustrating for us. And to be honest, I don’t know where we fit in or how.”

'It permeates society'

The drone of tones sound in Phoenix Fire Station 18, the busiest station in Arizona, that stands near the corner of Camelback Road and 23rd Avenueand at the nexus of substance abuse and crises in the Valley.

"Unconscious person," the automated dispatcher voice bellows across the living quarters.

A few moments later, a call to a wreck on nearby Interstate 17.

Then to a woman in a cluttered single-story assisted-living house who is having a "problem with staying awake," possibly related to a drug overdose — firefighters dose her with Narcan, a treatment that spurs only a marginal effect, before loading her into an ambulance.

There's no such thing as a "routine" call. Anyone in EMS will tell you that.

Such "Low acuity" calls — the closest thing to "routine" — have long strained emergency systems. But while they often don't constitute a life-threatening emergency, they are increasingly rooted in opioid use and abuse.

No tracking effort can capture with 100 percent certainty the scope of the issue.

“When you look at how much drug addiction and overdoses permeate the city, it’s scary,” McDade said. "It permeates society, but it’s also a huge part of what we do.”

'Hands are tied' on solutions

Phoenix firefighters from Engine 18 tend to a woman during a drug-overdose call at a west Phoenix apartment.(Photo: Nick Oza/The Republic)

The Arizona Department of Health Services has tallied 5,500 possible opioid overdoses statewide since enhanced monitoring took effect in June, including 820 deaths. First responders — primarily firefighters and other emergency medical personnel — have administered more than 3,600 doses of overdose-reversing naloxone in that time.

As one of the largest fire departments, Phoenix crews confront the opioid epidemic daily.

But whereas law enforcement can ramp up crackdowns and policy makers can rewrite laws or debate regulations, firefighters and emergency medical personnel remain in a state of limbo within an endless battle.

Ashley Losch, a firefighter in Glendale and department spokeswoman, agreed their "hands are tied" when it comes to stemming the surge in overdoses. Referring to legislation signed last month, she said she was uncertain new laws would result in sweeping change on the streets so many expect — at least immediately.

Heroin use continues to be a driving force, brought on in part by prescription addiction.

Those who are already addicted will still seek substances.

Overdoses will keep happening.

And without additional funding or new programming, first responders will remain on the back end of any longer-term solution.

"We are reactionary and we are intermediaries," Losch said. "We see them for 20, 30 minutes, and that's it. Did we have an impact? We saved their lives for the moment. But we are just intermediaries."

'Safe Stations' as a solution

Fed up with being the last resort, some fire departments across the country have adopted more proactive measures.

Those dealing with substance-abuse issues — opioids or otherwise — are encouraged to go to any city station where they can talk to on-duty firefighters. Crews conduct a medical assessment and will arrange transportation to the nearest hospital in the event someone is suffering an emergency,

No insurance. No medication. No cost.

In the time since it was launched in May 2016, Manchester's program has been replicated in communities across the country — President Donald Trump even acknowledged the department's efforts.

Crews assisted their 3,000th patient in January, and "hundreds" of departments big and small have reached out to learn how to replicate the program, said Chris Hickey, the emergency medical services officer for the city's fire department who drafted the initial program proposal.

"It just goes to show the scope of the problem and the lack of the resources that are out there," Hickey told The Arizona Republic. "The whole premise was designed around getting people connected with the resources that were available instead of trying to make the phone calls on their own."

Though overdoses continued an increase in the first year of the program, fatalities decreased by more than 24 percent. That was because of greater naloxone access as well as connections people made through the Safe Station program, Hickey said.

The formalized program cemented how rescuers should handle "walk-in patients" who aren't experiencing an immediate emergency. That group historically might have hit a barrier since there was no medical need, a trip to the hospital wasn't warranted and relationships with community-based options centers were informal.

Whereas a lot of focus is spent on drug-side issues, programs like Safe Stations are a new, low-cost angle in confronting the demand and treatment sides of opioid addiction, said Sarah Wetter, a research scholar at the Center for Public Health Law and Policy at Arizona State University.

Fire stations are already viewed as "safe places" strategically located across communities, Wetter said. So it makes sense to fold them into the mix and empower thousands of firefighters to become more proactive, connecting people with treatment or serving as safe disposal sites for expired medications.

”I think historically, the conversation surrounding first responders has really centered on naloxone distribution," Wetter said. "But if you want to really be proactive, you have to talk about that next step.”

So, will it happen in Arizona?

Lawmakers last month approved the Arizona Opioid Epidemic Act, legislation that limits initial pain-pill fills to five days for “opioid naive” patients, and imposes a maximum dosage limit for many others seeking new prescriptions.

The package of policy changes was largely based on the state's "opioid action plan" that outlined a host of legislative priorities in dealing with overdoses.

Though a Safe Station program was mentioned in that document, the Arizona Department of Health Services on Thursday deferred to individual fire departments and said it is "not specifically something ADHS is working on."

Shelly Jamison, assistant chief with the Phoenix Fire Department, said she was not aware of the Safe Station program. She did say, however, that fire stations in Phoenix informally operate with many of the same abilities as those with the program elsewhere.

Those services just haven't been publicized, and the partnerships with providers aren't crystallized like they are with Safe Station programs.

"Any fire station, when the trucks are in there, is filled with a group of professional problem-solvers," she said, encouraging people to take advantage of their services if needed. "While we don't have something designated as such right now, we're still very good sources of information for things like that."

Other options, like para-medicine

Arizona does not have a first-responder model for opioid-related support, the state's action plan concluded.

Officials are working to change that, both by expanding partnerships between first responders and hospitals and streamlining treatment referral processes.

The state Health Department and the University of Arizona announced recently they would partner on a $3.1 million grant from the Substance Abuse and Mental Health Services Administration. Officials with the university's Center for Rural Health said they will work to instruct EMS on screening, intervention and treatment referrals involving patients addicted to opioids.

The funds are aimed primarily at pre-hospital substance abuse recognition and emergency treatment. Still, efforts are part of a broader move to shift EMS from a reactive model to a more proactive mode of community-based screenings, referrals and treatment, said Taylor A. George, section chief for the Bureau of EMS and Trauma System at ADHS.

A major part of that will be expanding the role of community para-medicine, an emerging program where firefighters — many of whom are EMTs and paramedics — have broadened roles, especially in at-risk communities.

Crews in places with such programs follow up with known users, check in with vulnerable communities and provide an access point for those seeking treatment.

"Big changes in the way that an industry has operated for 40 or 50 years take a little bit of time," George said, adding that different communities have different resources and different needs. "... The ability to adapt to those depends on the local jurisdiction."